Treatment of conversion disorder in the 21st century: have we moved beyond the couch?

Conversion disorder (CD) is classified in the Diagnostic and Statistical Manual for psychiatry as a subtype of Somatoform Disorders. CD patients present with a wide range of neurologic signs and symptoms and are typically referred to psychiatry after investigations fail to yield a medical or neurologic diagnosis that can adequately explain their disability. The cause of CD is unknown and the underlying brain mechanisms remain uncertain. Controlled studies of the treatment of CD are rare, and almost all information about the effectiveness of particular interventions is descriptive and anecdotal. Comorbid psychiatric disorders are common and require attention. An initial treatment hurdle involves overcoming patients' anger about being given a psychiatric diagnosis when they consider the problem to be entirely physical. Physicians, too, are often uneasy about the diagnosis, doubting the unconscious etiology of the disorder and confusing it with malingering. They are also concerned that a "real" (i.e., medical or neurologic) diagnosis has been missed, and this concern can negatively affect the success of psychiatric treatment interventions. Psychotherapy, either psychodynamic or cognitive-behavioral, continues to be the mainstay of treatment. Key elements of successful treatment include (1) open-mindedness on the part of the physician, with willingness to reconsider the diagnosis if recovery does not occur as expected with psychiatric intervention; (2) patient education about mind-body interplay, using common examples such as the worsening of tremor with anxiety or impaired athletic performance when confidence has been undermined; (3) involvement of allied health professionals such as physiotherapists, occupational therapists, and speech pathologists, when appropriate; (4) hospitalization, if the patient is severely disabled or lives in a situation that supports disability or sabotages recovery; (5) attention to the presence of comorbid medical, neurologic, and psychiatric conditions that may have been overlooked or neglected when the diagnosis of CD was made, or which develop during the course of treatment.